VA OIG: Health Information Management Medical Documentation Backlog

Executive Summary

“VA healthcare staff rely on medical records to manage veterans’ care. Since the Veterans Access, Choice and Accountability Act passed in August 2014, more than 70 million appointments with non-VA providers have been completed, generating at least as many medical documents.1Non-VA providers send medical documents to VA medical facilities for staff to scan or import into patients’ electronic health records (EHRs), which helps ensure continuity of care by healthcare providers. Incorporating these non-VA medical documents into the patients’ EHRs is critical to supporting patient care because it contributes to more complete, accurate, and readily accessible health records that guide clinicians’ decisions. An August 2017 site assessment summary by Cerner Corporation consultants and a VA team outlined VA staff concerns with document scanning backlogs.2In June 2018, the President signed the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act, expanding opportunities for community care for veterans from non-VA providers. The MISSION Act has the potential to significantly increase the volume of documentation VA medical facilities will receive from outside providers for scanning, as well as any related backlog. The VA Office of Inspector General (OIG) performed this audit to determine if Veterans Health Administration (VHA) medical facilities are scanning and entering medical documentation into patients’ EHRs accurately and in a timely manner.”

What the OIG Found

“Significant medical documentation backlogs have occurred VHA-wide in part because VA medical facility staff did not scan documentation and enter electronic medical records into patients’ EHRs in a timely manner. Based on data provided by the eight facilities visited and the 78 facilities interviewed, the audit team calculated that as of July 19, 2018, VA medical facilities had a cumulative medical documentation backlog of paper documentation that measured approximately 5.15 miles high and contained at least 597,000 individual electronic document files dating back to October 2016…” Read the full 49-page report here.

Source: Health Information Management Medical Documentation Backlog – August 21, 2019. VA OIG.

 

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